Marie Tierney

Short‐ and long‐term effects of gestational diabetes mellitus on healthcare cost: a cross‐sectional comparative study in the ATLANTIC DIP cohort

This paper examines the association between gestational diabetes mellitus and costs of care during pregnancy and 2–5 years post pregnancy.

Feasibility, acceptability and uptake rates of gestational diabetes mellitus screening in primary care vs secondary care: findings from a randomised controlled mixed methods trial.

AbstractAims/hypothesisIt is postulated that uptake rates for gestational diabetes mellitus (GDM) screening would be improved if offered in a setting more accessible to the patient. The aim of this study was to evaluate the proportion of uptake of GDM screening in the primary vs secondary care setting, and to qualitatively explore the providers’ experiences of primary care screening provision.MethodsThis mixed methods study was composed of a quantitative unblinded parallel group randomised controlled trial and qualitative interview trial. The primary outcome was the proportion of uptake of screening in both the primary and secondary care settings. All pregnant women aged 18xa0years or over, with sufficient English and without a diagnosis or diabetes or GDM, who attended for their first antenatal appointment at one of three hospital sites along the Irish Atlantic seaboard were eligible for inclusion in this study. Seven hundred and eighty-one pregnant women were randomised using random permutated blocks to receive a 2xa0h 75xa0g OGTT in either a primary (nu2009=u2009391) or secondary care (nu2009=u2009390) setting. Semi-structured interviews were conducted with 13 primary care providers. Primary care providers who provided care to the population covered by the three hospital sites involved were eligible for inclusion.ResultsStatistically significant differences were found between the primary care (nu2009=u2009391) and secondary care (nu2009=u2009390) arms for uptake (52.7% vs 89.2%, respectively; effect size 36.5 percentage points, 95% CI 30.7, 42.4; pu2009<u20090.001), crossover (32.5% vs 2.3%, respectively; pu2009<u20090.001) and non-uptake (14.8% vs 8.5%, respectively; pu2009=u20090.005). There were no significant differences in uptake based on the presence of a practice nurse or the presence of multiple general practitioners in the primary care setting. There was evidence of significant relationship between probability of uptake of screening and age (pu2009<u20090.001). Primary care providers reported difficulties with the conduct of GDM screening, despite recognising that the community was the most appropriate location for screening.Conclusions/interpretationCurrently, provision of GDM screening in primary care in Ireland, despite its acknowledged benefits, is unfeasible due to poor uptake rates, poor rates of primary care provider engagement and primary care provider concerns.n Trial registrationhttp://isrctn.org ISRCTN02232125n Funding This study was funded by the Health Research Board (ICE2011/03)

Can the Onset of Type 2 Diabetes Be Delayed by a Group-Based Lifestyle Intervention in Women with Prediabetes following Gestational Diabetes Mellitus (GDM)? Findings from a Randomized Control Mixed Methods Trial

Objective. To evaluate a 12-week group-based lifestyle intervention programme for women with prediabetes following gestational diabetes (GDM). Design. A two-group, mixed methods randomized controlled trial in which 50 women with a history of GDM and abnormal glucose tolerance postpartum were randomly assigned to intervention (n = 24) or wait control (n = 26) and postintervention qualitative interviews with participants. Main Outcome Measures. Modifiable biochemical, anthropometric, behavioural, and psychosocial risk factors associated with the development of type 2 diabetes. The primary outcome variable was the change in fasting plasma glucose (FPG) from study entry to one-year follow-up. Results. At one-year follow-up, the intervention group showed significant improvements over the wait control group on stress, diet self-efficacy, and quality of life. There was no evidence of an effect of the intervention on measures of biochemistry or anthropometry; the effect on one health behaviour, diet adherence, was close to significance. Conclusions. Prevention programmes must tackle the barriers to participation faced by this population; home-based interventions should be investigated. Strategies for promoting long-term health self-management need to be developed and tested.

Health related quality of life two to five years after gestational diabetes mellitus: cross-sectional comparative study in the ATLANTIC DIP cohort

BackgroundThere is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related quality of life (HRQOL) for the mother in the short or long term. In this study we examined HRQOL in a group of women who had GDM in the index pregnancy 2 to 5xa0years previously and compared it to a group of women with normal glucose tolerance (NGT) in the index pregnancy during the same time period.MethodsThe sample included 234 women who met International Association of Diabetes Study Groups (IADPSG) criteria for GDM in the index pregnancy and 108 who had NGT. The sample was drawn from the ATLATIC-DIP (Diabetes In Pregnancy) cohort – a network of antenatal centers along the Irish Atlantic seaboard serving a population of approximately 500,000 people. HRQOL was measured using the visual analogue component of the EQ-5D-3xa0L instrument in a cross-sectional survey.ResultsThe difference in HRQOL between GDM and NGT groups was not significant when adjusted for the effects of the covariates. HRQOL was negatively affected by increased BMI and abnormal glucose tolerance post-partum in the NGT group. Moderate alcohol consumption was positively associated with HRQOL in the NGT group only. The negative association with smoking on HRQOL was substantially higher in the GDM group.ConclusionsA diagnosis of GDM does not appear to have an adverse effect on HRQOL, 2 to 5xa0years after the index pregnancy. On the contrary, its diagnosis might lead to the development of coping strategies, which, consequently attenuates the adverse effect of the subsequent acquisition of abnormal glucose tolerance post-partum on HRQOL. Women whose pregnancy was affected by GDM are more susceptible to the adverse effects on HRQOL of alcohol use and tobacco smoking.

The cost-effectiveness of screening for gestational diabetes mellitus in primary and secondary care in the Republic of Ireland

Aims/hypothesisThe aim of the study was to assess the cost-effectiveness of screening for gestational diabetes mellitus (GDM) in primary and secondary care settings, compared with a no-screening option, in the Republic of Ireland.MethodsThe analysis was based on a decision-tree model of alternative screening strategies in primary and secondary care settings. It synthesised data generated from a randomised controlled trial (screening uptake) and from the literature. Costs included those relating to GDM screening and treatment, and the care of adverse outcomes. Effects were assessed in terms of quality-adjusted life years (QALYs). The impact of the parameter uncertainty was assessed in a range of sensitivity analyses.ResultsScreening in either setting was found to be superior to no screening, i.e. it provided for QALY gains and cost savings. Screening in secondary care was found to be superior to screening in primary care, providing for modest QALY gains of 0.0006 and a saving of €21.43 per screened case. The conclusion held with high certainty across the range of ceiling ratios from zero to €100,000 per QALY and across a plausible range of input parameters.Conclusions/interpretationThe results of this study demonstrate that implementation of universal screening is cost-effective. This is an argument in favour of introducing a properly designed and funded national programme of screening for GDM, although affordability remains to be assessed. In the current environment, screening for GDM in secondary care settings appears to be the better solution in consideration of cost-effectiveness.

Screening for gestational diabetes mellitus in primary versus secondary care: The clinical outcomes of a randomised controlled trial.

AIMSnTo examine the clinical outcomes of screening for gestational diabetes mellitus (GDM) in primary care versus secondary care, in the Irish healthcare system.nnnDESIGN AND METHODSnA parallel group randomised controlled trial (RCT) of screening for GDM in primary versus secondary care was used to examine (i) prevalence, (ii) gestational week of screen, (iii) time to access specialist care, and (iv) maternal and neonatal outcomes. In total 781 women were recruited for screening in primary care (n=391) or secondary care (n=390).nnnRESULTSnThe prevalence of GDM and gestational week of screen were similar in both locations. There was a trend towards a longer time to access diabetes care in primary care (24days) versus secondary care (19days), a difference of 5days (p=0.09). Women screened in primary care also showed a trend towards a higher rate of large for gestational age (LGA) infants (20%) than those screened in secondary care (14.7%), (p=0.09). There were no differences between groups in maternal outcomes.nnnCONCLUSIONSnThis RCT suggests that screening for GDM in secondary care may be associated with potentially faster time to access specialist antenatal diabetes care and possibly lower LGA rates. Further research is needed to clarify these findings and to improve the delay in accessing specialist care requires an urgent focus. Further research is needed to test these findings in other health systems.

Perspectives on the provision of GDM screening in general practice versus the hospital setting: a qualitative study of providers and patients

Objective A novel gestational diabetes mellitus (GDM) screening programme which involved offering screening at the patients general practitioner (GP) compared with the traditional hospital setting was trialled. This study investigates perspectives of involved stakeholders on the provision of GDM screening at both settings. Design Thematic analysis of the perspectives of stakeholders involved in the receiving and provision of GDM screening in both the GP and hospital settings drawn from focus groups and interviews. Participants 3 groups of participants are included in this research—patient participants, GP screening providers and hospital screening providers. All were recruited from a larger sample who participated in a randomised controlled screening trial. Purposeful sampling was utilised to select participants with a wide variety of perspectives on the provision of GDM screening. Setting Participants were recruited from a geographical area covered by 3 hospitals in Ireland. Results 4 themes emerged from thematic analysis—namely (1) travel distance, (2) best care provision, (3) sense of ease created and (4) optimal screening. Conclusions The influence of travel distance from the screening site is the most important factor influencing willingness to attend for GDM screening among women who live a considerable distance from the hospital setting. For patients who live equidistance from both settings, other factors are important; namely the waiting facilities including parking, perceived expertise of screening provider personnel, access to emergency treatment if necessary, accuracy of tests and access to timely results and treatment. Optimal screening for GDM should be specialist led, incorporate expert advice of GDM screening, treatment and management, should be provided locally, offer adequate parking and comfort levels, provide accurate tests, and timely access to results and treatment. Such a service should result in improved rates of GDM screening uptake. Trial registration number ISRCTN41202110.

Factors influencing lifestyle behaviours during and after a gestational diabetes mellitus pregnancy

Objective: This qualitative study examined the healthy lifestyle behaviours undertaken during and after a pregnancy complicated by gestational diabetes mellitus (GDM) and the factors that influenced the likelihood of undertaking of such behaviours. Methods: Semi-structured telephone interviews were conducted with women who had a pregnancy complicated by GDM in the previous 3–7 years. Interviews were analysed using a theoretical thematic analysis approach. Results: Thirteen women provided interviews as part of this study. Women typically engaged in healthy behaviours in terms of diet, physical activity and glucose monitoring during their GDM pregnancy, but generally these behaviours were not maintained postpartum. Women appear not to be intrinsically motivated to engage in healthy lifestyle behaviours, but rather require the support of an extrinsic motivator such as their unborn child or the support of healthcare professionals. A gap exists between womens knowledge of their increased long-term diabetes risk and the behaviours which they undertake to reduce this risk in the postpartum period. Conclusion: Women with previous GDM need increased support in the postpartum period to assist them to develop self-management and prioritisation skills to take control of their increased type 2 diabetes mellitus risk.